Nextech Named 2024 Best in KLAS: Ambulatory Specialty EHR

«  View All Posts


ICD-10 Challenges for Healthcare Providers and Payers

By: Nextech | January 12th, 2015

ICD-10 Challenges for Healthcare Providers and Payers Blog Feature

The switch to ICD-10 means dramatic changes to the U.S. healthcare infrastructure in terms of one-on-one patient care, clinical documentation, and insurance claims processing. It’s not enough to fully implement ICD-10 in a private practice with doctors and their personnel. Physicians also need to ensure that all of their business partners (i.e. EHR software vendors, payers, and clearinghouses) are up to speed and will be ready for ICD-10 by October 1, 2015.

The following is a closer look at two of the challenges that healthcare providers and payers specifically face in the midst of an ICD-10 transition, along with how to overcome them.

1. Payers will start ICD-10 mapping to align ICD-10 codes with their business rules

Get Prepared with Your Medical Coding Most payers already began ICD-10 mapping in their ICD-10 implementation to establish the most fitting and precise translations for their business rules. ICD-10 mapping is arguably the hardest facet of this code transition for many payers, who typically utilize General Equivalence Mappings (GEMs) as their fundamental mapping system. To suit its business rules, a payer may disable (or add) a small number of codes in the processing of claims.

For example, Anthem Inc. (a leading managed healthcare company in the Blue Cross and Blue Shield Association) has suspended the unspecified angina code 413.9 – which maps for about 24 variations of combination codes concerning atherosclerotic heart disease with angina. Program Director of ICD-10 Code Set Competency Center at Anthem, Carol Spencer, says that they would’ve had 45,000 pending claims if they didn’t disable the map for those combination codes and business rule. However, Anthem keeps the maps for other angina-related codes, such as 120.8 and 120.9. Anthem and other payers decide business rule by rule; there are normally hundreds of thousands of rules and myriad codes within these rules.

Payers also take measures to eliminate code variations in ICD-10 that might result in reimbursement disparities. In other words, payers don’t want to over or underpay their physicians because of inaccurate or unsuitable ICD-10 codes for diagnoses and clinical treatment rendered. Therefore, payers have to act on synchronizing ICD-10 with their fee schedules.

Spencer advises healthcare professionals to contact their payers for a written record of what they are doing regarding their mapping practices. Physicians should request their payer’s source for mapping and how they are customizing that map for their particular business rules. Doing this will give physicians a better handle of what ICD-10 codes will be accepted for what clinical practices by their payers without a problem.

2. ICD-10 testing conducted between healthcare providers and payers

Start Coding 1CD-10 Codes to Get Prepared NowThe main challenge for ICD-10 testing is that it proves far too costly or simply not feasible for a large number of payers and healthcare providers. Why? Payers have hundreds, if not thousands, of physicians connected to them. Conducting ICD-10 testing on top of processing day-to-day claims for every single affiliated physician and other entities through the chain requires tremendous resources in terms of manpower, time, and money.

Keep in mind that every claim processing path between physicians and payers is different and might diverge into multiple paths depending on the number of partner and process combinations. To add ICD-10 claims testing to this insurance infrastructure will undoubtedly stretch most payers thin. Larger payers who have adequate resources will fare better with ICD-10 testing than smaller payers, just as larger medical centers and private practices generally experience a smoother ICD-10 transition than smaller medical facilities.

However, every physician preparing for ICD-10 should still contact their payers (and clearinghouses) to find out if ICD-10 testing is a possibility before the October 1, 2015 deadline. Physicians should take advantage of all testing opportunities with their business partners. In order to avoid ICD-10 errors that lead to heavy claim delays and denials, healthcare professionals and payers must work in tandem where possible to nail down and mitigate risks associated with partial or incorrect ICD-10 coding, potential variations in the claims process resulting from ICD-10 codes, and EHR functionality with ICD-10 codes.

A few tips for the actual ICD-10 testing process. Go through medical records and select a number of the most common diagnoses and medical treatments in your office, then code these using ICD-10 codes. Ensure the physician’s clinical documentation matches the level of detail and specificity necessary for ICD-10. Another testing option could be to double code (ICD-9 and ICD-10) medical services in real-time as the healthcare professional sees patients. This activity will enable physicians and their medical billers/coders to get some hands-on ICD-10 training while servicing patients in a fast-paced environment.

In addition to the above challenges, physicians face many of their own monetary and training challenges related to ICD-10, making it essential to learn how to prepare for ICD-10 and how to avoid disruption from the implementation of ICD-10.

Download the whitepaper and get ready for ICD-10!